Selected Podcast
NAFLD (Fatty Liver & Fibroscan)
Sharlina Dhom PA and Amber Jackson APRN discuss NAFLD (Fatty Liver & Fibroscan) They highlight diagnostic testing including open access Fibroscan and they outline treatment options and process for PCP to manage or refer to GI
Featuring:
Learn more about Sharlina Dhom, PA
Sharlina Dhom, PA | Amber Jackson, APRN
Sharlina Dhom, PA specialties include Digestive Health, Gastroenterology, Hepatology - Liver Care.Learn more about Sharlina Dhom, PA
Amber Jackson, APRN specialties include Gastroenterology, Digestive Health, Hepatology - Liver Care, Inflammatory Bowel Disease (IBD).
Transcription:
Melanie Cole (Host): Welcome to Expert Insights with the Carl Foundation Hospital. I'm Melanie Cole. Joining me in a panel today is Amber Jackson. She's an advanced practice registered nurse and Sharlina Dham she's a physician's assistant and they are both specialists in digestive health at the Carl Foundation Hospital. They're here to highlight non-alcoholic fatty liver disease and fibro scan. Thank you ladies for joining us today. Sharlina, I'd like to start with you. Can you just help us to understand the magnitude of the epidemic of non-alcoholic fatty liver disease, what it means to primary care physicians and patients? What have you been seeing in the trends?
Sharlina Dhom: Non-alcoholic fatty liver disease is definitely on the uptick. I think in both. Diagnosis in general. We've also. Recognize that non-alcoholic fatty liver disease as a cause for liver transplant is on the rise too. This probably coincides with the increasing, obesity epidemic, the increase in diabetes, high cholesterol, metabolic syndrome in general. So the medical field in general is seeing more non-alcoholic fatty liver disease in our clinic that specializes in liver care is seeing a rise in it as well.
As far as how it impacts primary care. I think that keeping that in the differential for elevated liver enzymes, is important. Non-alcoholic fatty liver can be shrugged off or not addressed urgently. And in some cases non-alcoholic fatty liver can lead to cirrhosis and more advanced disease. So the detection and treatment is important.
Melanie Cole (Host): You made very good points for primary care providers, and Amber discuss some of those risk factors and underlying conditions that might signal those red flags to those primary care physicians?
Amber Jackson: So certainly, diabetes is probably our number one risk factor, particularly uncontrolled type two diabetes. Obesity, as Sharlina mentioned, is one of our biggest risk factors. Just, you don't have to have diabetes in order to have fatty liver. High cholesterol, high triglycerides would also play a role, and obviously alcohol consumption does contribute to fatty liver as well. But, we're talking about non-alcoholic fatty liver, in these instances, but that can play a role.
Sharlina Dhom: I would like to add, there are some less common causes, definitely by far the metabolic syndrome is the most common, underlying risk factor we see in rare instances, it can be a medication like Tamoxifen, or even some over the counter medicines. But like Amber said, most of the time it's the metabolic syndrome.
Amber Jackson: In addition, other insulin resistant, conditions like PCOS are also risk factors.
Melanie Cole (Host): That's so interesting and you both make such great points for other providers. Now Sharlina, as we're talking about the causes, the risk factors, the epidemic of obesity and type two diabetes. In action on the part of primary care physicians, you know, you mentioned the red flags that you would like them to really pay attention to. What do we know about the association between NAFLD and stroke? Because that association with cardiovascular disease is becoming more appreciated. So what can you tell us about stroke risk, and then we're going to get into referral to liver specialists?
Sharlina Dhom: Non-alcoholic fatty livered disease, heart disease, strokes, they all have kind of the same underlying risk factors. So I think that's the. common, factor there. People that have non-alcoholic fatty liver, it's important to kind of intervene as early and as much as we can to also reduce their risk of heart attack and stroke. Again, diabetes is a very common underlying issue, which increases your risk of those other conditions as well.
Melanie Cole (Host): So, I guess they all tie together is the real key message here for other providers is that these all tied together for the conditions, the causes and the risk factors. So Amber, when do you feel it's important to refer to a liver specialist? What are some of the criteria to send somebody there for diagnoses and treatments?
Amber Jackson: So I think that there's a couple things, that would certainly prompt a referral. Certainly abnormal liver function tests on lab results would prompt a referral or, abnormal imaging findings, like splenomegaly or evidence of portal hypertension. I think a lot of times we see, evidence of non-alcoholic fatty liver or hepatic staytosis on imaging incidentally, and a lot of times clinicians don't Always, know what to do with that. so in the absence of, elevated liver enzymes, that would maybe be a good time for the primary care doctor to order a fibro scan, to really get an idea of, is there any significant staytosis or fibrosis there?
It kind of gives us a, a quantification. of what's seen on that imaging. And then depending on what that result looks like, fibrosis is graded on a scale of one to four. So grades one and two really don't have a whole lot of clinical impact, but, that could be something that's managed by the primary care doctor, but grades three and four, we would really kind of encourage those people to get into the specialist.
Melanie Cole (Host): Well then Amber, why don't you expand a little bit on Open Access, FibroScan. What is that? Tell us a little bit about the role and limitations of current diagnostics.
Amber Jackson: So vibration controlled transient, elastography otherwise known as FibroScan. it's routinely used to grade, fibrosis based on liver stiffness also being developed to grade hepati c stayatosis really helped stasis really helps us quantify that. It helps either prompt or to tour the need for a liver biopsy, which liver biopsy still kind of remains that gold standard for diagnosing non-alcoholic fatty liver disease. But this is a, less invasive approach.
Sharlina Dhom: I would like to add that the process of a FibroScan is noninvasive. Most of our patients do really well with it. it's kind of like a thumping sensation on the right rib cage. It's again, less invasive than a liver biopsy. We have lots of openings. Patients are able to get in pretty quickly. Whenever a primary care provider orders it, one of our liver providers will interpret the fibro scan, send the results and recommendations back to the referring provider. And then they can make a decision based on that, whether they want the patient to establish care in clinic.
Amber Jackson: I'd also like to add the fibro scans, very similar to an ultrasound, but instead of a picture, we're gonna get numbers that kind of quantify that degree of fibrosis and stayatosis.
Melanie Cole (Host): Well, then let's speak about treatment options and process for PCPs to manage or to refer to the liver specialists. So Sharlina, just tell us a little bit about management what's involved because it's really comprehensive and multidisciplinary? Yes?
Sharlina Dhom: Yes, lifestyle modifications are always our number one intervention. things like lowering your, consumption of processed foods, sugary foods, carbohydrates, all the same recommendations we make for general healthy living. Another important thing is reducing red meat and high fructose corn syrup. We do refer to a dietician frequently whenever we're able to, for help with guidance on the fatty liver diet, the Mediterranean diet is also a good one to follow.
As far as medication for fatty liver, there's not a lot of, evidence for a specific medication to help with non-alcoholic fatty liver. Vitamin E, Milk Thistle have been shown in some studies to be beneficial. the newer studies have shown Ozempic, and Metformin. To be beneficial. However, without a diagnosis of diabetes that can be difficult to get covered, with diabetes, sometimes they're already at that point or they're on insulin. So mostly the treatment is diet, lifestyle, weight loss, overall lifestyle changes.
Amber Jackson: I'd like to add, just kind of modifying the risk factors for cardiovascular disease, as you mentioned before, you know, there's a big link between stroke an, non-alcoholic fatty liver disease, but these kind of go back to those underlying risk factors. Particularly hypertension and high cholesterol, hyperlipidemia.
Melanie Cole (Host): Well, that's an important point that you made in Amber. I'd like you to tell us about the Carl Foundation Hospital's approach to the management of patients with non-alcoholic fatty liver disease. What's unique about what you're doing? Speak to providers about the clinic. How it works and this real interdisciplinary approach.
Amber Jackson: So there are two advanced practice providers, Sharlina and myself who primarily see the, liver population with our, physicians who see, these patients as well. We generally see, what the underlying causes, could be for their. Abnormal liver function test. Most of the time, most of these patients will get a FibroScan usually that same day in clinic. it's important to know that they should be fasting for about four hours if they need to have a FibroScan. and then we're able to discuss those results that same day with the patient and make, recommendations for lifestyle changes. and set them up with the nutritionist.
And most of these folks, if, they're making changes will see a change in their FibroScan, which we can usually repeat, you know, in six months to a year's time to compare for differences. Certainly if that fibro scan is trending, towards the higher degree of fibrosis, then we certainly start to talk about a liver biopsy, working with our interventional radiology department to accomplish that.
Melanie Cole (Host): I'd like to give you each a chance for a final thought. Sharlina, why don't you start? What would you like other providers to know about non-alcoholic fatty liver disease and the key takeaways from the message today?
Sharlina Dhom: I would like other providers to know that fatty liver is reversible, which is great. If it's caught early enough, if the damage progresses, it can cause cirrhosis. And that's one of the main things we are trying to prevent here in our hepatology clinic. Another thing I would like to add is that one benefit of being seen in our clinic is we can rule out other conditions. Some patients have non-alcoholic fatty liver in addition to other liver diseases as well. So we can rule out those. and also in the event that. Non-alcoholic fatty liver does progress to Nash, which is non-alcoholic steato hepatitis, or progresses to Nash cirrhosis, we do have excellent resources here at Carl to take care of those patients if they get to that point.
Melanie Cole (Host): Then Amber, last word to you. if you were to offer the best advice to primary care providers, when they are doing well visits and lifestyle checks with their patients, what would you like them to make sure to pay attention to?
Amber Jackson: I think I would, really pay attention to, diet and making sure that they're managing the weight, because that's the biggest thing that I think that we see correlate with the fatty liver population, especially for those who have higher BMIs. and if they're not making progress in those weight loss journeys, then, bringing up the possibility of bariatric surgery, because ultimately this is going to affect multiple aspects of their health.
Melanie Cole (Host): So important. Thank you both for joining us today and for more information, and to get connected with one of our providers, please visit carl.org or for a listing of Carl providers and to view Carl sponsored educational activities, please visit our website at carlconnect.com. That concludes this episode of Expert Insights with the Carl Foundation Hospital. I'm Melanie Cole.
Melanie Cole (Host): Welcome to Expert Insights with the Carl Foundation Hospital. I'm Melanie Cole. Joining me in a panel today is Amber Jackson. She's an advanced practice registered nurse and Sharlina Dham she's a physician's assistant and they are both specialists in digestive health at the Carl Foundation Hospital. They're here to highlight non-alcoholic fatty liver disease and fibro scan. Thank you ladies for joining us today. Sharlina, I'd like to start with you. Can you just help us to understand the magnitude of the epidemic of non-alcoholic fatty liver disease, what it means to primary care physicians and patients? What have you been seeing in the trends?
Sharlina Dhom: Non-alcoholic fatty liver disease is definitely on the uptick. I think in both. Diagnosis in general. We've also. Recognize that non-alcoholic fatty liver disease as a cause for liver transplant is on the rise too. This probably coincides with the increasing, obesity epidemic, the increase in diabetes, high cholesterol, metabolic syndrome in general. So the medical field in general is seeing more non-alcoholic fatty liver disease in our clinic that specializes in liver care is seeing a rise in it as well.
As far as how it impacts primary care. I think that keeping that in the differential for elevated liver enzymes, is important. Non-alcoholic fatty liver can be shrugged off or not addressed urgently. And in some cases non-alcoholic fatty liver can lead to cirrhosis and more advanced disease. So the detection and treatment is important.
Melanie Cole (Host): You made very good points for primary care providers, and Amber discuss some of those risk factors and underlying conditions that might signal those red flags to those primary care physicians?
Amber Jackson: So certainly, diabetes is probably our number one risk factor, particularly uncontrolled type two diabetes. Obesity, as Sharlina mentioned, is one of our biggest risk factors. Just, you don't have to have diabetes in order to have fatty liver. High cholesterol, high triglycerides would also play a role, and obviously alcohol consumption does contribute to fatty liver as well. But, we're talking about non-alcoholic fatty liver, in these instances, but that can play a role.
Sharlina Dhom: I would like to add, there are some less common causes, definitely by far the metabolic syndrome is the most common, underlying risk factor we see in rare instances, it can be a medication like Tamoxifen, or even some over the counter medicines. But like Amber said, most of the time it's the metabolic syndrome.
Amber Jackson: In addition, other insulin resistant, conditions like PCOS are also risk factors.
Melanie Cole (Host): That's so interesting and you both make such great points for other providers. Now Sharlina, as we're talking about the causes, the risk factors, the epidemic of obesity and type two diabetes. In action on the part of primary care physicians, you know, you mentioned the red flags that you would like them to really pay attention to. What do we know about the association between NAFLD and stroke? Because that association with cardiovascular disease is becoming more appreciated. So what can you tell us about stroke risk, and then we're going to get into referral to liver specialists?
Sharlina Dhom: Non-alcoholic fatty livered disease, heart disease, strokes, they all have kind of the same underlying risk factors. So I think that's the. common, factor there. People that have non-alcoholic fatty liver, it's important to kind of intervene as early and as much as we can to also reduce their risk of heart attack and stroke. Again, diabetes is a very common underlying issue, which increases your risk of those other conditions as well.
Melanie Cole (Host): So, I guess they all tie together is the real key message here for other providers is that these all tied together for the conditions, the causes and the risk factors. So Amber, when do you feel it's important to refer to a liver specialist? What are some of the criteria to send somebody there for diagnoses and treatments?
Amber Jackson: So I think that there's a couple things, that would certainly prompt a referral. Certainly abnormal liver function tests on lab results would prompt a referral or, abnormal imaging findings, like splenomegaly or evidence of portal hypertension. I think a lot of times we see, evidence of non-alcoholic fatty liver or hepatic staytosis on imaging incidentally, and a lot of times clinicians don't Always, know what to do with that. so in the absence of, elevated liver enzymes, that would maybe be a good time for the primary care doctor to order a fibro scan, to really get an idea of, is there any significant staytosis or fibrosis there?
It kind of gives us a, a quantification. of what's seen on that imaging. And then depending on what that result looks like, fibrosis is graded on a scale of one to four. So grades one and two really don't have a whole lot of clinical impact, but, that could be something that's managed by the primary care doctor, but grades three and four, we would really kind of encourage those people to get into the specialist.
Melanie Cole (Host): Well then Amber, why don't you expand a little bit on Open Access, FibroScan. What is that? Tell us a little bit about the role and limitations of current diagnostics.
Amber Jackson: So vibration controlled transient, elastography otherwise known as FibroScan. it's routinely used to grade, fibrosis based on liver stiffness also being developed to grade hepati c stayatosis really helped stasis really helps us quantify that. It helps either prompt or to tour the need for a liver biopsy, which liver biopsy still kind of remains that gold standard for diagnosing non-alcoholic fatty liver disease. But this is a, less invasive approach.
Sharlina Dhom: I would like to add that the process of a FibroScan is noninvasive. Most of our patients do really well with it. it's kind of like a thumping sensation on the right rib cage. It's again, less invasive than a liver biopsy. We have lots of openings. Patients are able to get in pretty quickly. Whenever a primary care provider orders it, one of our liver providers will interpret the fibro scan, send the results and recommendations back to the referring provider. And then they can make a decision based on that, whether they want the patient to establish care in clinic.
Amber Jackson: I'd also like to add the fibro scans, very similar to an ultrasound, but instead of a picture, we're gonna get numbers that kind of quantify that degree of fibrosis and stayatosis.
Melanie Cole (Host): Well, then let's speak about treatment options and process for PCPs to manage or to refer to the liver specialists. So Sharlina, just tell us a little bit about management what's involved because it's really comprehensive and multidisciplinary? Yes?
Sharlina Dhom: Yes, lifestyle modifications are always our number one intervention. things like lowering your, consumption of processed foods, sugary foods, carbohydrates, all the same recommendations we make for general healthy living. Another important thing is reducing red meat and high fructose corn syrup. We do refer to a dietician frequently whenever we're able to, for help with guidance on the fatty liver diet, the Mediterranean diet is also a good one to follow.
As far as medication for fatty liver, there's not a lot of, evidence for a specific medication to help with non-alcoholic fatty liver. Vitamin E, Milk Thistle have been shown in some studies to be beneficial. the newer studies have shown Ozempic, and Metformin. To be beneficial. However, without a diagnosis of diabetes that can be difficult to get covered, with diabetes, sometimes they're already at that point or they're on insulin. So mostly the treatment is diet, lifestyle, weight loss, overall lifestyle changes.
Amber Jackson: I'd like to add, just kind of modifying the risk factors for cardiovascular disease, as you mentioned before, you know, there's a big link between stroke an, non-alcoholic fatty liver disease, but these kind of go back to those underlying risk factors. Particularly hypertension and high cholesterol, hyperlipidemia.
Melanie Cole (Host): Well, that's an important point that you made in Amber. I'd like you to tell us about the Carl Foundation Hospital's approach to the management of patients with non-alcoholic fatty liver disease. What's unique about what you're doing? Speak to providers about the clinic. How it works and this real interdisciplinary approach.
Amber Jackson: So there are two advanced practice providers, Sharlina and myself who primarily see the, liver population with our, physicians who see, these patients as well. We generally see, what the underlying causes, could be for their. Abnormal liver function test. Most of the time, most of these patients will get a FibroScan usually that same day in clinic. it's important to know that they should be fasting for about four hours if they need to have a FibroScan. and then we're able to discuss those results that same day with the patient and make, recommendations for lifestyle changes. and set them up with the nutritionist.
And most of these folks, if, they're making changes will see a change in their FibroScan, which we can usually repeat, you know, in six months to a year's time to compare for differences. Certainly if that fibro scan is trending, towards the higher degree of fibrosis, then we certainly start to talk about a liver biopsy, working with our interventional radiology department to accomplish that.
Melanie Cole (Host): I'd like to give you each a chance for a final thought. Sharlina, why don't you start? What would you like other providers to know about non-alcoholic fatty liver disease and the key takeaways from the message today?
Sharlina Dhom: I would like other providers to know that fatty liver is reversible, which is great. If it's caught early enough, if the damage progresses, it can cause cirrhosis. And that's one of the main things we are trying to prevent here in our hepatology clinic. Another thing I would like to add is that one benefit of being seen in our clinic is we can rule out other conditions. Some patients have non-alcoholic fatty liver in addition to other liver diseases as well. So we can rule out those. and also in the event that. Non-alcoholic fatty liver does progress to Nash, which is non-alcoholic steato hepatitis, or progresses to Nash cirrhosis, we do have excellent resources here at Carl to take care of those patients if they get to that point.
Melanie Cole (Host): Then Amber, last word to you. if you were to offer the best advice to primary care providers, when they are doing well visits and lifestyle checks with their patients, what would you like them to make sure to pay attention to?
Amber Jackson: I think I would, really pay attention to, diet and making sure that they're managing the weight, because that's the biggest thing that I think that we see correlate with the fatty liver population, especially for those who have higher BMIs. and if they're not making progress in those weight loss journeys, then, bringing up the possibility of bariatric surgery, because ultimately this is going to affect multiple aspects of their health.
Melanie Cole (Host): So important. Thank you both for joining us today and for more information, and to get connected with one of our providers, please visit carl.org or for a listing of Carl providers and to view Carl sponsored educational activities, please visit our website at carlconnect.com. That concludes this episode of Expert Insights with the Carl Foundation Hospital. I'm Melanie Cole.